Falling through the drug doughnut hole

“Can you imagine having to pay a $4,000 prescription bill all in one month?”

Pharmacist Jeff Carson of Oakdell Pharmacy said there’s a problem with Medicare Part D prescription assistance that is causing big problems for a small group of people.

“I had it happen three times this month,” Carson said.

The Part D plan has patients making copays until the retail cost of their meds reach $2,700. At that point, the patients face the doughnut hole, when they pay their own way until their “true out-of-pocket costs exceed $4,350,” according to the Medicare Part-D site.

That plan was designed, Carson said, to make the patient “a conscious contributor to keeping the cost of health care down.”

“But it’s penalizing those people who take really expensive medicines.”

In other words, people might be taking several medications that aren’t particularly expensive. Once they reach the gap level, as they continue to pick up this and that prescription, their costs during the gap period are spread out. (If their needs continue beyond the gap amount, they then pay 5 percent.)

But if they’re on a very pricey prescription, when they arrive at the doughnut hole, they get hit with the cost all at once.

“I had a patient come in about a week ago who is taking a very expensive prescription,” Carson said, adding that the Oakdell Pharmacy treats a lot of chronic pain with meds that can cost thousands of dollars. “When this patient hit their gap, that prescription was giong to cost them around $4,000 for one prescription.”

“The issue with this patient being on chronic pain medication is, if they stop taking their prescription, they could die from withdrawal,” he said. Other patients might not face death but serious, debilitating pain.

The pharmacist then struggled with the question of whether a cheaper appropriate subsistute could be found, or whether the person should just be admitted straight to the hospital, where the medication would be covered.

“But then, the cost to the health care system goes up.”

“As pharmacists, we’re coming up with creative ways to help a patient,” Carson said, “and the ways that we’re doing that are ways we shouldn’t have to.”